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			<div class="m_head">病人基本资料</div>
			<table class="qi_table" id="tf_table" width="60%" border="0" cellspacing="1" cellpadding="0">
			  <tr><th width="15%">投诉人姓名</th><td width="35%"><input class="dq_text" name="" type="text" /></td><th width="15%">与患者关系</th><td width="35%"><input class="dq_text" name="" type="text" /></td></tr>
                  <tr><th>患者诊疗编号</th><td colspan="3"><input name="" type="radio" value="" />门诊 <input name="" type="radio" value="" />住院 
                      <input class="dq_text" name="input" type="text" value="请填写门诊编号" /></td></tr>
                  <tr><th>患者姓名</th><td><input class="dq_text" name="" type="text" /></td><th>患者性别</th><td><input class="dq_text" name="" type="text" /></td></tr>
                  <tr><th>患者年龄</th><td><input class="dq_text" name="" type="text" /></td><th>联系电话</th><td><input class="dq_text" name="" type="text" /></td></tr>
                  <tr><th>联系地址</th><td colspan="3"><input class="lc_text" name="" type="text" /></td></tr>
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		   <div class="m_head">投诉信息</div>
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			   <tr><th>投诉科室</th><td><select name=""><option>请选择科室</option><option>内科</option><option>外科</option><option>消化内科</option></select></td><th>投诉人员</th><td><input class="dq_text" name="input2" type="text" /></td></tr>
			  <tr><th>投诉分类</th><td colspan="3"><select name=""><option>请选择分类</option><option>医院收费太高（用低价吸引消费，实际收费太多）</option><option>医院医生水平太差（治疗效果太差）</option><option>医院服务太差（导医服务差、医生服务差）</option><option>医院广告宣传太离谱</option><option>其他</option><option>不作选择，只发表评论</option></select></td></tr>
			  <tr><th>投诉内容</th><td colspan="3"><textarea class="lc_textarea" name="" cols="68" rows="10">&nbsp;</textarea></td></tr>
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